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Screen Shot 2016-01-12 at 10.53.06 PMWhat She Left Behind

By Ellen Marie Wiseman

This book is composed of two interweaving stories. Clara, a woman who lived in the 1930s was committed to a mental institution against her will based on her wealthy father’s unhappiness about her Italian immigrant boyfriend and her refusal to marry the rich guy that her father picked out for her. The other story is about a current day teenager named Izzy who is a foster child of Peg and Harry after having lived with several previous foster parents since her mother unexplainably murdered her father. Peg is working on a museum project examining newly discovered suitcases of belongings of former patients (including those of Clara) of a now closed psychiatric facility, in order to gain some understanding of their lives. Izzy helps out with this project and finds the diary of Clara and becomes interested in her life.

Being a psychiatrist, I was initially drawn to this book with the idea that I would gain some insight into the lives and treatments of psychiatric patients living in the first half of the twentieth century. This was the case and it included vivid description of the treatment that was done at that time such as ice baths, insulin shock therapy and electroconvulsive therapy (ECT).

Although I never worked in a state hospital, when I toured them in the late 1960s, such treatments except occasional ECT under humane conditions were things of the past. As far as the possibility of someone spending most of their life committed to a mental institution based on the word of her father when she clearly did not have a mental illness, I would like to think that this would not have been possible. Certainly, in modern times from my experience someone being hospitalized against their will would have to go through a legal hearing with the patient being assigned an attorney if they don’t have one. Once in a hospital with treatment with modern-day medicines (which were not really available until the 1950s) most mental illness can be put at least in temporary remission with such treatment. Today, there would be reviews by multiple doctors with no mandate to keep the person in the hospital against their will unless they were a danger to themselves or others due to a mental illness. I would hope that nothing like Clara’s situation could occur today. Obviously, I can’t speak for every state hospital in the United States and certainly things were different in the 1930s.

There was another aspect of Clara’s case was particularly disturbing to me in that the psychiatrist in charge of her care was depicted as a mean, cruel, selfish man who was mainly responsible for Clara’s lost life. I felt it was an unfair indictment, which suggested all psychiatrists of that time might have been of the same cloth. I understand that the author has the creative choice to develop characters in whatever fashion she chooses. I probably would not be complaining if the character were a dishonest lawyer who did unsavory things in the interest of an interesting storyline but nevertheless, I felt that this book was stigmatizing my profession.

There was particular theme of this book, which also had a special interest to me. Three characters in the book were driven to try to understand their early origins. Izzy, understandably could not fathom why her beloved mother murdered her father. This ultimately led her to empathize with a schoolmate who had some parental trauma. It contributed to her mission to find Clara’s daughter who was essentially separated from her at birth, and hand over her mother’s diaries so she could know about her mother’s story. Clara’s daughter led a life of yearning to know what happened to her mother and Clara similarly went through life wanting to know what happened to her daughter. This is a variation of a theme, which I have seen played out in many people’s lives as well as in some interesting movies. Persons, sometimes separated at birth or when they are quite young often yearn to know their biological parent or parents with whom they may have had no relationship for decades. I have reflected on the psychodynamics of these issues in an earlier posting in this blog. Therefore, I was particularly interested to see how they played out as major motivating factors in the characters in this book.

I believe the author Ellen Wiseman has created an intriguing story that will hold the interest of the reader whether or not you come from a psychiatric background.

 

Screen Shot 2015-11-18 at 6.27.58 PMA Common Struggle: A Personal Journey through the Past and Future Mental Illness and Addiction   By: Patrick J. Kennedy and Stephen Fried

This is a story, told in the first person of Patrick J. Kennedy. It is really two stories presented to us simultaneously. It is about Patrick Kennedy, son of Edward Kennedy and nephew of JFK and Bobby Kennedy. He has been a US congressman from Rhode Island for eight terms and was one of the staunch advocates for parity legislation, for mental illness, and addiction. Yet at the same time that he was leading the fight in the United States Congress to bring about these major changes in our healthcare system, he himself was secretly battling mental illness and addiction.

An important part of his personal story was a discussion of alcoholism in his family. Not only was the author an alcoholic but his brother, mother, and father, Ted Kennedy also struggled with this condition. It is significant that all of them except his father ultimately recognized their problem and entered various programs to help themselves. His mother battled alcoholism for a prolonged period of time and yet her condition was not recognized by family members despite the fact that they knew about several hospitalizations and treatment programs that she had undergone.

One of the most revealing insights about his father that he revealed in this book is how Ted Kennedy was traumatized by the tragic death of his three brothers, JFK, Bobby Kennedy, and his oldest brother, Joe Jr., who was killed in World War II. An additional major trauma for Ted Kennedy was the death of the young woman in Chappaquiddick, an incident well covered by the press.

It was not a simple pathway for the author to recognize his own problems. Even after a period of therapy with Psychiatrist Peter Kramer, author of the well known book (Listening to Prozac). Kennedy felt this treatment was helpful but did not eliminate his addiction problem or allow full acceptance of his bipolar condition. He vividly described how he would convince himself that he didn’t have any problems if he didn’t drink in public or take “illegal” drugs.

Patrick Kennedy served in the Rhode Island legislature and was elected as the youngest member of the US Congress in 2004 during a period that his addiction and mental illness was hidden from the public. It was also pretty much hidden from himself.

His colleagues in the US Congress ultimately became aware of his attempts to hide his drinking problem. Kennedy describes an important event for him when in 1996, Minority Leader, Dick Gephardt, offered him the prestigious chairmanship of the Congressional Campaign Committee on the condition that he stop drinking. This made him realize how he was denying that he had a problem that was known to others.

It wasn’t until 2005 that he publicly admitted that he was suffering from a mood disorder that was being treated by a psychiatrist. While his own struggle continued, he became more effective in his advocacy in the US Congress. One misconception he believed had to be clarified concerned Nancy Reagan’s “Just Say No” campaign against drugs. He felt that this missed the main point that addiction is not something you can simply say no to, just as you can’t say no to cancer. It is a disease and by implying you can just say no stigmatized people who have the genetic propensity to have this disease.

As much as the story of Kennedy’s recognition of his own illness of addiction and mental disease and how he battled it is quite enlightening, the battle for a definitive bill in the US Congress is just as revealing.

The events leading up to the 2008 Wellstone and Domenici Mental Health Parity and Addiction Equity Act are quite interesting and complicated. They are also quite personal to Patrick Kennedy. It took place at the time that he was relapsing to alcohol and painkillers and also was having an exacerbation of his bipolar condition. While Patrick Kennedy was one of the leading champions in the House of Representatives for this legislation, his father, Ted Kennedy, was a major supporter of this bill in the US Senate. This was also at a time that the senior Kennedy was dying of a brain tumor. Compromises had to be made in the bill and the Senate was reluctant for the legislation to be as comprehensive in various aspects and details of the bill as was wanted by the House of Representatives. There also was a question how the legislation would deal with the new surge of mental health problems occurring in soldiers returning from the war. There was a concern that it should cover PTSD as well as addiction in the returning servicemen. Patrick Kennedy described the dramatic moment that his dying father came to the senate floor to vote for the final version of the bill to the applause of the US Senate.

Even with the passage of this extraordinary legislation, the battle for adequate parity for healthcare support was far from over. The proof and the success of this landmark bill would depend on the implementation by the federal and state governments and certain local rulings are expected to eventually reach the Supreme Court. The 2016 presidential race can certainly also be expected to impact the success of implementation of this legislation. As of this writing, it appears that the Republican candidates may be reluctant to support the implementation of this legislation and provide funding for new programs.

Patrick Kennedy decided to leave the United States Congress in 2010. Since departing from Congress, he has continued to be a leading advocate to bring about implementation of the 2008 legislation for mental illness and addiction. In this regard, among many other things, he has worked with two important organizations in which he plays very active roles. The Kennedy Forum (kennedyforum.org) gathers experts in mental health and addiction and holds important conferences that they hope will ensure implementation of the 2008 legislation. They are also committed to promoting a translation of neuroscience into the preventative and treatment interventions for mental health and addiction. The second organization in which Patrick Kennedy is involved is One Mind (onemind.org), which is dedicated to the promotion and support of “brain health” and creating a fast track for treatment. Their current focus is on new approaches to treat and cure PTSD but they look forward to applying solutions for all brain disease including depression, Parkinsons, ALS, dementia, Alzheimer’s disease, and addictions.

Patrick Kennedy does not bemoan problems. He is clearly a man not only with a vision but with plans and solutions. He concluded his book with a scorecard of how we should rate our public officials who have the opportunity to pass legislation and make changes. Also at the end of the book, he had a section for people who are dealing with their own mental illness and addiction. He tells them not to be alone in this struggle and how important it is to get treatment. Finally, sandwiched in this book was a series of photographs of many well known members of his family. It brought back many memories to this reader of the great accomplishments of many members of the Kennedy family and of the tragic events that they experienced.

It should be noted that at the time that Patrick Kennedy wrote this book, he was three and a half years sober. He has shown that he is a very accomplished and insightful man. I believe we are going to hear a great deal about him in his advocacy. He has provided in this book a valuable historical account of the reasons to fight for the proper care of mental illness and addiction. I am sure he has a bright future and many people will benefit by his skills and his passion.

 

Robert Wallerstein: 65 Years at the Heart of Psychoanalysis – Interviewed and Produced  by Shelley Nathans (Available in DVD and streaming from www.psychotherapy.net)

Screen Shot 2015-12-03 at 12.37.20 PMIf you are a psychoanalyst, a psychoanalytically oriented psychiatrist, mental health professional or a student of psychoanalysis, you will appreciate this interview with Dr. Robert Wallerstein by Dr. Shelley Nathans. It presents Dr. Wallerstein as a warm, knowledgeable man who understands the legacy of his profession.

Dr. Wallerstein was born in Germany in 1921 and came to New York City with his mother at age two, to join his father, a physician who had come the previous year.  He grew up in the depression and recalled apples being sold by grown men for five cents apiece in order to make a living. He graduated from high school at the age of 15 and was sent to live with his uncle in Mexico City and then returned to Columbia University, graduating in 1941 at the age of 20. After medical school, he joined the army as the war was ending. He then took his psychiatric and psychoanalytic training at Menninger Clinic. His years at the Menninger Clinic, of course, are quite intriguing. I never realized that the program there had at one time 100 residents, which was one-eighth of the total number of psychiatric residents in the United States. He notes that during his psychiatric residency, the main tools to treat severe mental illness were Chloral Hydrate, ECT and lobotomies.

Although his training was in the United States, he was a witness and then a participant in the growth of psychoanalysis in this country. In the interview, Dr. Wallerstein was able to trace the plight of Jewish psychoanalysts in Germany and then in Austria, who during the pre-World War II years were not able to take Arian patients and then ultimately had to leave their native country. American psychoanalysts set up funds to bring these psychoanalysts to the United States, mostly to New York. Dr. Wallerstein described the fascinating details of this situation and also spoke of the German, probably Nazi oriented psychoanalysts, who came to Brazil and the unusual circumstances that happened in that country in the post-war years. He had occasion to conduct an investigation into the details of this situation in the 1980s.

As a faculty member at the Menninger Clinic he proudly described hiring a young psychiatrist from Chile by the name of Otto Kernberg. He also discussed his two personal analyses and candidly admits that he felt that they could have gone further than they did. He tells about meeting his wife Judith and her career as a well-known researcher who studied and wrote about the impact of divorce on children.

Dr. Wallerstein was barely at his mid-career when he moved to San Francisco in 1966 and became established at Mt. Zion Hospital. Perhaps, his greatest insights into the psychoanalytic world came during his front row seat as President of the American Psychoanalytic Association and then President of the International Psychoanalytic Association. He describes the famous “lawsuit” which, of course, was a turning point in allowing non-psychiatrist to join the American Psychoanalytic Association and take an equal role in psychoanalysis in the United States. From his unique perspective, Dr. Wallerstein was able to reflect on the roles of different schools of psychoanalysis and their influence in the United States and even labeled Anna Freud’s recognition as the “crown princess.”

Dr. Shelley Nathans showed excellent technique in her interview as she stayed out of the way of Dr. Wallerstein and gently led him to new topics. This interview was done in July 2013 one and half years before  Wallerstein died. While this DVD was only 1 hour and 22 minutes, there are a total of over five hours of the interview with him available in the archives. We are very appreciative of the efforts of the team led by Dr. Nathans  that captured this interview and most of all, to Dr. Robert Wallerstein for his many contribution to our profession.

To learn more information about obtaining this and other related videos, contact psychotherapy.net

The ethical position of the American Psychiatric ( APA) Association and the code of ethics for psychiatrists about torture came to prominence about 10 years ago when I was Speaker of the Assembly of the American Psychiatric Association. At this time the Assembly endorsed the position of the Board of Trustees of the APA about this issue. Recently this topic has surfaced again as described in the article below in the the APA News . I would suggest that this article should be read  and then for further clarification I would like to present a video interview that I had  in 2009   with the late Dr. Abraham Halpern. Dr. Halpern was a prominent American psychiatrist who was leading spokesperson  on number of ethical issues.

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And now please view the interview that I did with Dr. Halpern on this subject in October 2009.     https://www.youtube.com/watch?v=oULhHzC8E_8

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Please feel free to add any comments that you have about this subject in the comment section below and they will be published shortly.

 

 

Screen Shot 2015-04-16 at 2.48.39 PMAs details emerge various news stories of terrorism, and murder/suicide events, there are important questions being raised about how should a mental health therapist approach patients who may have the potential for violence towards themselves or others.

I would suggest that the following questions should be considered.

  1. What should a psychiatrist or another mental health therapist do when a patient says that they have had thoughts about killing themselves in a violent manner that could injure other people? Would the response be different if the self-destruction was only directed towards themselves in a non-violent manner such as taking an overdose as compared to potentially hurting other people as well? Should there be a different response to the above question if the patient is a school teacher, a bus driver, an airline pilot, or a scientist who works with Ebola?
  2. If a therapist knows that a patient has been suicidal in the past but is not so at present with therapy and medication, should the therapist be obligated to inform the patient’s employer if the job is a critical one such as those described above? Also, how we do factor in the fact that depression can be a recurrent condition?
  3. What are the possible consequences  if therapists were mandated to report patients who have had suicidal thoughts or violent fantasies?

General Discussion

Screen Shot 2015-04-16 at 7.25.57 PMJust having fleeting suicidal thoughts does not make someone a risk for hurting themselves. Similarly, having an angry murderous thought toward someone who you might resent does not make you a potential killer. There are many factors which a clinician must consider in evaluating the suicidal and danger potential of a patient. Is the patient psychotic? Is the patient having a severe depression which might include not sleeping or eating, crying, losing weight, etc ? Has the person acted on impulses in the past? Is there a history of violence towards self or others? Does the therapist and the patient feel comfortable that the patient would talk to the therapist if he or she felt that the feelings were intensifying? Does the patient have an immediate means to violence, such as access to a gun? Are there family members who can help monitor the patient in between sessions? These and many other factors enter into the evaluation of the seriousness of the threat that the patient may have to themselves or others. This is tricky business, but mental health professionals do it all the time.

The overwhelming majority of people with mental illness are not dangerous to themselves or other people. It should also be noted that mental health therapists do not have a sure method of predicting dangerous behavior in the future. We may be good in retrospect at explaining behavior and actions as the result of psychological factors (called psychic determinism), but we cannot claim the ability to predict behavior with great accuracy. We know a great deal about various forms of mental illness such as  schizophrenia where there is a break with reality. In most of these situations, the diagnosis is quite clear. Depression affects a very large number of people. There is a wide range of etiological factors of depression from grieving and situations involving loss and disappointment to biological types of major depression which can come on without any particular relationship to a loss or disappointment. There are also can be variations of mood such as bipolar or major depression which can even be at a psychotic level.Screen Shot 2015-04-17 at 12.50.56 PM

Suicidal thoughts often accompany various forms of depression. There can be passive thoughts such as a person who does not care about anything and might not want to eat or drink or take care of themselves. In such situations, a person frequently expresses the idea that they do not care if they wake up or not. Sometimes, persons may act suicidal or make suicidal threats or even try to hurt themselves as part of “cry for help.” In other words, the main thought of such person would be a desire to be stopped and given help. This doesn’t mean that they might not actually seriously hurt themselves.

People can become depressed to the point where they feel they cannot tolerate life or may feel worthless and that they do not deserve to live. Such a person might choose a suicidal method that would be more likely to be fatal. In some situations, this person, is intent on making a statement to someone else in their life, and they would want their suicide to have an impact on a family member or someone close to them. Sometimes, tremendous anger at themselves or others is part of the motivation for suicidal thinking.

Screen Shot 2015-04-16 at 2.51.07 PMAs it is well-known by police, some suicides are connected with a murder of someone else, usually a person well-known to the perpetrator. This may frequently be a family member or someone where there is an intense conflictual relationship. Sometimes, the suicide and the murder of the other person may involve a work situation such as a boss or a co-worker. The circumstances of someone being fired or humiliated at work or school might fit in to this category. These are not common, but they do happen.Screen Shot 2015-04-16 at 2.50.44 PM

This brings us to the situation of a suicide and multiple or mass murders. While such situations are extremely rare, they become very well publicized and well remembered. Sometimes they become examples for copycat acts by someone else. Limited research upon this group suggests that major depression is frequently present in the person who carries out this act. Also anger and rage and the feeling of being wronged may be present. There also may be some grandiose or narcissistic feelings where the perpetrator wants to become famous or remembered. While alcohol and drugs can always be a factor as it can loosen up one’s conscience and any inhibitions, it is not always present in this particular type of suicide connected with mass murder, since it often takes careful planning and requires a clear mind to carry them out. In retrospect, a study of each of these cases usually reveals particular stresses, rejection, and usually tremendous anger.

Can a therapist see the makings of a potential catastrophe and do something to prevent it? The answer is yes, we do that all the time when we work with people who have suicidal thoughts, but we can’t do it every time. Treatment works! But not all the time. There are many people who have experienced severe depression even with suicidal thoughts and even may have made a suicidal attempt and then recovered with treatment. Treatment can be psychotherapy, medication, or both. This is the reason that therapy has to be available, and a person should be able to enter the therapy and feel secure that they can express all their thoughts in a safe environment

But what if the therapist concludes at some point in the treatment that the patient is an immediate serious threat to themselves or someone else? At that point, there is an obligation for the therapist to hospitalize the patient. Hopefully, the patient would agree to such hospitalization. But even if the patient does not agree, there is a procedure (that varies from state to state) in which patients can be hospitalized against their will. In the State of California, it is called a “5150”, and if necessary, the police will assist a therapist based on the information provided from the mental health professional to take the patient  to the hospital. Then at the hospital, based on the information provided by the therapist and any family or friends available plus another evaluation by a mental health professional at the hospital, a patient can be legally hospitalized against his or her will. Then there can be subsequent legal proceedings to extend this hospitalization.Now, you may ask isn’t this breaking the confidentiality of the doctor-patient relationship? Yes of course it is, but this is obviously in the patient’s best interest. On occasion, during the course of therapy, the patient will ask me, “Is everything we say in therapy confidential?” I would reply, “Yes, unless I feel you were a true danger to yourself or someone else, and then I would act accordingly.”

Screen Shot 2015-04-16 at 2.47.41 PMThere is another situation to consider. What if the therapist becomes aware that the patient is seriously suicidal and/or a danger to someone else but they are not in present in the therapist’s office? Perhaps, they have left a message for the therapist or they do not show up for an appointment and the family described some behavior that the therapist understands means a danger situation to the patient or someone else. In such a case, the therapist is obligated to notify the police and have them attempt to find the patient and institute a “5150” based on the information that the therapist has provided. In California, the law further mandates that if the therapist feels that there is a clear danger to someone else , and the therapist knows who that person is, the therapist has to act according to the Tarasoff case. The Tarasoff case involved a situation at the University of California where a therapist knew that the patient would attempt to hurt another person. As a result of this case, in California, if a therapist believes that another person is in danger, the therapist must notify that person or be sure that that person has been informed by the police. Every effort must be made to contact the person who is believed to be in danger. So therefore, reflect on the thought, what if the therapist is treating an airline pilot and the therapist came to believe that the pilot who was not available to be brought to the hospital but might be flying a plane which he could be planning to  crash as part of a suicide murder. According to the Tarasoff precedent, the therapist would be obligated not only to notify the police and try to hospitalize the patient, but would also be obligated to be sure the airline was notified of the potential danger.

So now let’s return to the three questions which I raised at the beginning of this article.

My answers would be as follows:

  1. If the therapist believes that the patient is a serious threat to hurt themselves or someone else, he or she should act in a responsible manner to hospitalize the patient as soon as possible, even if this hospitalization has to be done on an involuntary basis. In California, if the patient has identified a threat to another person, every effort should be made to notify that person of the threat (in other states, there may be variation of this expectation). I believe the responsibility of the therapist is the same no matter what kind of work responsibility or employment the patient may have.
  2. If the therapist knows that the patient has been suicidal in the past but is not a suicidal threat to themselves or any danger to anybody else at the present time, the therapist is not obligated to inform the employer even if the job is a critical one, such as an airline pilot or a scientist working with dangerous bacteria, etc. The fact that depression is a recurrent condition does not change my opinion on this issue. An employer can make a decision that people with a history of epilepsy, or heart disease, or depression or suicidal ideation, should not work in critical positions. I would not necessarily agree with this position, but an employer certainly could make such a policy. Also, if a therapist is requested by his or her patient to provide information to an employer, the therapist should do that in a truthful manner.
  3. If therapists were mandated to report patients who have suicidal thoughts or violent fantasies, this would create a situation where people who had emotional conditions that might on occasion bring up suicidal thoughts or fantasies of violence would be quite reluctant to seek help. Therefore, people who would benefit by treatment would not be receiving it and I believe this would create, overall, a more dangerous situation.

Disclaimer

I am not an attorney nor do I claim expertise in legal issues which often differ from state to state. I also am not necessarily reflecting the ethical position of the American Psychiatric Association or other professional organizations. I am writing as one experienced psychiatrist who has confronted variations of these questions in clinical practice and has discussed such issues with my colleagues, mentors and students over the years.

I would also recommend a recent article in the New York Times by Erica Goode dated April 9, 2015 titled, “The Mind of Those Who Kill, and Kill Themselves.”

Dr. Blumenfield is the Sidney Frank Distinguished Professor Emeritus at New York Medical College. He currently is in private practice in Woodland Hills, California. For more information about Dr. Blumenfield go to  http://mblumenfieldmd.com/

 

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